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SCHATZ

Norman J. Schatz, MD was born in Philadelphia in 1936. Respect for authority was never his forte. But he is a disarming stand-up comedian. His Borscht Belt humor and his stunning clinical acumen have made him among the finest and most beloved of neuro-ophthalmologists. When he is around, forget piety. He has probably examined more neuro-ophthalmic patients than anyone else-at least so he says. Those who think they are about to report an unusual case had best check with Schatz first because he probably saw five of them last week.

The first neurology-trained neuro-ophthalmologist to reach stardom, he is a founder of the Walsh Society and the Rocky Mountain Neuro-Ophthalmology Club, which later merged to become the North American Neuro-Ophthalmology Society (NANOS). Although he has suffered from angina nearly all his adult life, and had his first heart attack in his mid-30s, he put together the most dynamic neuro-ophthalmology service in North America, pooling the clinical resources of Wills Eye Hospital with the academic resources of the University of Pennsylvania. Together with his colleagues and fellows, he has published on virtually every strange phenomenon in the field of neuro-ophthalmology. His weekly conferences at Wills, at which he would imitate any accent and act out any finding, were strictly SRO. Many of the leaders in present-day neuro-ophthalmology got there because they wanted to be like Schatz.

This interview took place on the terrace of his apartment on Key Biscayne, Florida, on April 10, 2005.

JDT: How did you come to grow up in Philadelphia?

NJS: Dad came to the United States in 1921. Later the family immigrated to Philadelphia in the area of Franklin and Girard Streets-the Jewish ghetto. The younger people like my father moved out of the ghetto to set up stores in the Polish-Irish neighborhoods. My father sold brassieres and lingerie. You could say that I grew up in ladies' underwear.

NJS: My father's sister had a children's clothing store; his brother had a shoe store, and his cousin had a butcher shop-all on the same block. We lived above the stores in adjacent buildings. The street was made up of our family and a few other Jewish merchants. You didn't talk to anyone but your own family.

JDT: What do you remember of your childhood?

NJS: It was a difficult time. After our soldiers left to fight in World War II, we would be accused-as Jews-of having started the war. Our store windows were broken again and again. Going to Carol Elementary School was life-threatening. I was beaten up nearly every day-and the school was only three blocks away!

When I was eight, my father became partially paralyzed. By the time I was 14, he couldn't walk. I thought everyone drove a car with hand controls.

JDT: Did you know what was wrong with him?

NJS: They said he had a spinal cord tumor. We were too young to understand. I later learned that he'd had radiation and a laminectomy. But all we knew then was that he had gone away and that the treatments had not helped. When I became a neurology resident, I realized that the laminectomy was from L2 to L5 yet his sensory level was at T8. I knew something was wrong. I took that information to Bernie Alpers.

JDT: Who was Bernie Alpers?

NJS: My mentor-one of the great influences in my life. He was chair of neurology at Jefferson Medical College and had written one of the classic textbooks of neurology (Alpers, BJ. Clinical Neurology. Philadelphia: F. A. Davis, 1945). In 1963, Alpers arranged for Dad to have his first proper myelogram, and we found that he had complete obstruction at T6 from Potts' disease of the spine. He had been in a tuberculosis sanatorium in 1934, but no one had ever connected his paralysis to the TB. In 1964, Joe Ransohoff, the great neurosurgeon at New York University, drilled out the body of T6, but Dad never got much better.

JDT: What do you remember of the junior high school years?

NJS: It was widely known that Jews could not survive in the local junior high, so the city allowed my older brother Jerry to go to Cook Junior High School in Olney, a 40-minute trolley car and subway ride away. One year later, I followed him there.

Then it came time for high school. My brother had started at Northeast Philadelphia High and was beaten up the first day. He lasted one term. We both decided to take the entrance examination for Central High School, which was very competitive, but we got in. The trip-by trolley, subway, and a one-mile walk-took 50 minutes. But the walk was through a Jewish neighborhood, so we were safe.

JDT: What about high school?

NJS: I was the class clown. But if you had asked me if I was funny, I would have said there wasn't anything humorous at all about my life. My brother was in Temple University, but I didn't think I was smart enough to follow him to college. I thought I'd help my father in the lingerie business. He said I was going to college. But I didn't apply.

JDT: What changed your mind?

NJS: All the smartest kids from my class at Central (High School) were going to Dickinson College (in Carlisle, PA). They could have gone to any college in America, but I think our college advisor in high school was getting $100 a kid for sending them to Dickinson. One weekend in the summer of 1953, the year I graduated, a few of my classmates who were accepted at Dickinson took a drive out to the campus and asked me to come along. After the dean of admissions toured us around, he said, “What are you doing next year?” I told him I was planning to get into lingerie. He said I should come to Dickinson.

NJS: They probably had an opening. I didn't make a move, but my father filled out the application and registered me at Dickinson. I didn't object. One of my friends from Central who was going was Joel Levin. He was the closest to a childhood friend that I had. The only time I ever left the neighborhood socially was to visit Joel at his place. His father was a physician and a painter. He allowed us to sit the basement of their house and watch him paint nudes.

JDT: What stands out from the Dickinson College experience?

NJS: Mark May, my roommate. He had a mind that required that everything be listed. And I had a mind that required chaos. It was a perfect match. I learned a discipline I never imagined, and he learned that a little bit of chaos is okay. There was a great social sharing in the dormitory and in the fraternity house. I got motivated. There were kids who really knew what they wanted to do. For instance, they took out six months in Washington to work for senators. I thought if I had to come out with some sort of degree, it would be in engineering. But all eight of my classmates from Central decided to go to medical school. I figured I could do that too. By this time, my father was bedridden, so I applied only to the three medical schools in Philadelphia.

JDT: What happened on the way to medical school?

NJS: I had my first interview at Temple. The man who interviewed me stood facing the wall and didn't talk. I quickly said all the things about me that were good. When I stopped, he said the interview was over. And I said, “No, this was not an interview. You haven't even turned around to look at me.” He buzzed the buzzer, a secretary came in to get me, but I said I would like to see someone else on the admissions committee. She said, “He is the admissions committee.” And that was that. I knew Temple had a quota for Jews. So did Jefferson, which did not even interview me. Penn and Hahnemann put me on the waiting list. I went out to look at the University of Pittsburgh, and they accepted me. But I wanted to be home with Dad, so I called Penn and Hahnemann and said, “I have to let Pitt know.” Hahnemann accepted me first, so I went there, partly because I knew that Mark May, with his obsessional study techniques, was going.

NJS: I roomed again with Mark May in a little apartment on 17th and Race Streets. The summer before starting medical school, I worked for Ray Truex, the famous anatomist, dissecting the bundle of His in whale hearts. Truex wanted these dissections for his next anatomy text. In the first year in medical school, Mark May and I became prosectors-we prepared the cadaver dissections for our fellow students. I learned how to find every structure-where it came from and where it went. Anatomy became the basis for how I thought about human disease.

JDT: What about the clinical years?

NJS: On my first day in surgery, I had to assist a Greek surgeon. After I finished draping, I sneezed and blew my mask onto the field. He yelled, “You will never come back to the operating room again!” I went to the dean and told him I was not allowed to going back to the surgical amphitheater. He said that was not possible. So I said, “I'll make a deal with you. I'll work a double shift doing pre-op work-ups and working the emergency room.” The dean said, “What am I going to do with you? Okay, go ahead.” And that is how I never went to the operating room again in my life.

NJS: Later in my first year of medical school. It affected both eyes, and at first all I could see was shadows. Luckily vision came back to normal within a few weeks. But they suggested I had multiple sclerosis, although I had no other neurologic manifestations. I was treated with intravenous corticosteroids. When the steroids were tapered, vision would go down a bit, so they kept them up for four months. And then I developed a steroid psychosis. But after six months of being confined to a psychiatric hospital, I got up and went back part time to medical school. In my junior year, I was inducted into the Alpha Omega Alpha society. I accepted my certificate, ate the dinner, and went back to my bed in the mental hospital.

But I graduated right on time. Then I became a rotating intern at Albert Einstein Hospital in Philadelphia. During that year of internship, I got so absorbed in medicine that the psychiatric demons disappeared.

JDT: Did any experience during internship stand out?

NJS: On obstetrics, I encountered a patient with pseudocyesis (false pregnancy). The intern before me had marked an “x” on her belly and had been listening to fetal heart sounds. I took over and did not hear any heart sounds. I did a pelvic and found the uterus was normal. I had to face a family-mother, father, and husband-waiting for this young girl to deliver. I was convinced that they were going to say that I had killed the baby. I told them that “sometimes a woman thinks she's pregnant and…I know this is difficult to understand, but…” And the husband interrupted me and said, “You know, I suspected that she wasn't pregnant.” I gave a sigh of relief and said, “I am going to help you all through this.” I went to the head of psychiatry at Albert Einstein and told him that I wanted to do the one-month post partum depression evaluations while I was on the obstetrics rotation. I helped develop the questionnaire. And that was a real experience-to see women with real psychiatric problems and to discover that I could be of benefit to them.

JDT: Why didn't you go into psychiatry?

NJS: I thought it was part of neurology. And I was influenced by Bernie Alpers. I had met him for the first time when I had optic neuritis. They took me to this fatherly man who gave me his neurology textbook and said if I ever became interested in neurology, I should call him.

JDT: So you decided on neurology because of Bernie Alpers?

NJS: Yes, and my father's illness, my own optic neuritis, and my interest in neuro-anatomy. I had a diagram in my mind that attached everything to everything else in the brain.

JDT: How does a guy who loves chaos also love neuro-anatomy?

NJS: That's just it. I needed something to make order out of my life. But there's a difference here. Mark May made lists. I hated lists. I liked looking and finding out.

JDT: Had you had any other exposure to neurology before you decided on it as a career?

NJS: Very little. At Hahnemann, neurology was taught by Marvin Hand, a psychiatrist. There weren't many neurologists in those days. You couldn't make a living as a neurologist. You did neuropsychiatry. The two exceptions in Philadelphia were Abe Ornstein at Penn and Bernie Alpers at Jefferson. Even Alpers had a big practice in psychiatry. He was originally trained in Europe as a neuropathologist, as many were. Because of Alpers, I went to Jefferson to do neurology.

NJS: A very interesting thing. I met Ron Burde (later to become a distinguished neuro-ophthalmologist and former editor of this journal), a third year medical student at Jefferson. He was assigned to my service-Alpers' service. Alpers had decided to have me come on his service as a first year resident, even though he usually only allowed third year residents. We made rounds at six in the morning. There was to be no food in the room; the patients had to be awake; you had to put a pillow under their knees so he could tap the reflexes; you turned out the lights so he could test the pupils, and so on. The night before these rounds, Ron Burde, this wonderfully bright medical student, and I would see all the patients and ask each other questions about them. I had to make sure I would know more than Ron did on rounds the next morning.

One morning I was presenting a patient to Alpers and I said, “This is a 73-year-old woman who is getting rapidly demented and has a movement disorder and she startles.” So Alpers said, “Well, that's very good. Now what is that?” And I said I did not know. Alpers, a tough middle European professor, said, rather gruffly, “Have you never heard of Creutzfeldt-Jakob disease?” I said, “No.” He said, “Don't come back to my service.” Another professor said don't worry, it will blow over. I said, “What do you mean, don't worry? I kiss my wife goodbye in the morning, and I have nothing to do.” Finally they sent me to purgatory-the neuropathology lab. I tried to appeal to Alpers, but he wouldn't take my calls. So one day I called his office and pretended I was his patient, Mr. Cohen, and that I'd become mixed up on my medications. His secretary put me through right away and I said, “Dr. Alpers, I do not want to go the neuropathology lab. If you think I can't be a clinical neurologist, fire me.” A week later, I got a reprieve-they sent to the neurology ward at Philadelphia General Hospital (PGH).

JDT: What did you find at PGH?

NJS: The administrators were so disorganized that they assumed I was the new attending. They gave me an office and a private residence. I came in at five in the morning, saw all the consults, and made rounds on all 2,000 patients in the hospital to look for good neurology cases to shift to the neurology ward. I told the nurses in the emergency room to route all the strokes to the Penn and Hahnemann services. Pretty soon my Jefferson service became an 80-bed stroke-free ward of the most interesting neurology cases ever seen.

About a year later, the administration finally figured me out. I was called into the office of the head of PGH and they asked why I was impersonating an attending. I said, “Explain something to me. Are you accusing me of practicing medicine too well?” They said well no, not exactly. They took away my office and my residence, but they didn't fire me.

A year later, Alpers came back to me and said, “They tell me you are the best resident we ever had. You can come back to my service.” I told him I wasn't ready. But six months later, I did come-when I felt I was finally ready. And we got on wonderfully. But Alpers had been right when he kicked me off his service in my first year-I really was unprepared.

NJS: Yes, Nathan Schlezinger. He was a senior neurologist and neuropsychiatrist at Jefferson who started seeing neuro-ophthalmology patients at Wills Eye Hospital in the early 1960s and bringing them over to Jefferson for inpatient work-ups. He was the closest thing to a neuro-ophthalmologist in Philadelphia at that time. He suggested I take night call at Wills. I liked it so much I decided to do a full rotation there, and I began helping him run the Wills neuro-ophthalmology clinic.

JDT: Why did you want to go over to Wills Eye?

NJS: Because at Jefferson we were flooded with neuro-ophthalmology patients, and I realized I knew nothing. I couldn't approach a patient without knowing how to look in the eye and what eye movements were about. When I was assigned to Wills, I grabbed neuro-ophthalmology patients out of the emergency room. The ophthalmologists were only too happy to unload them. The more I saw, the more I liked. I wanted to come back to Jefferson on staff as a neuro-ophthalmologist. Alpers said OK, but go do a fellowship. And that is when I had my famous encounter with Lawton Smith.

JDT: What encounter?

NJS: Lawton Smith was publishing everything in sight. California-Hoyt-was too far for me to go. I thought I could take my family to Miami. I called Lawton. (Here Schatz begins imitating Smith's famous South Carolina twang…). He said, “Hi, Dockey, you come on down in April to the Wilmer Meeting in Baltimore and stay at that hotel across the street, and we're gonna have dinner that night.” So I go to the Wilmer meeting and everywhere people are talking about cataracts and vitreous. I don't even know what vitreous is, and I'm thinking I made a terrible mistake. I wait for Lawton for dinner, and no one comes. Finally I get a call from him, and he says, “Dockey, I'm havin' dinner with the big dogs, and Dr. (David) Cogan and Dr. (Frank) Walsh say you can't train a neurologist to be a neuro-ophthalmologist. Bye now.” And he hangs up.

I'm so upset, I go to bed. Later that night, the phone rings, and it is Lawton. He says, “Dockey, we're gonna have breakfast at six am.” Hangs up. Next morning, I meet him for breakfast. I'm sitting at a table with Cogan, Walsh, Hoyt, and Smith. Then Smith suddenly says, “Next year when Dr. Schatz here, the neurologist, comes with me, it is going to be fantastic.” I am puzzled at this because he hasn't even interviewed me. Hoyt nudges me and says, “I have to tell you what happened at dinner last night. Lawton said, ‘You wanna hear something funny, Bill? A neurologist applied to do neuro-ophthalmology with me. Ha ha, everybody knows you can't train a neurologist.’ I told him ‘Lawton, I'm taking my first neurologist next year.’ And Lawton said, ‘All right, mine will be better than yours.’ ” So I got my fellowship with Lawton on a dare from Hoyt.

JDT: Who was that first Hoyt-trained neurologist?

NJS: It wasn't Bob Daroff, who came two years later. It was John Loeffler, from the Washington University neurology program.

NJS: It was neuro-ophthalmology and evangelism. I learned how someone with skill can really impose his will. I also discovered how rich my own beliefs were to be able to let Lawton know that I had something more valuable - my Jewish heritage - than anything he could ever give me. I did go to one Bible class - only one. I thought you were supposed to interact. So when somebody said something that sounded wrong, I objected. They pulled me aside and said you're not allowed to do that. But once Lawton figured me out, he was very respectful and left me alone. We had a wonderful year together.

JDT: What did you learn from him?

NJS: A fantastic communication skill with patients. And logic and animation. Eye movements had noises. An energy level so high that we never stopped going. On days when he wasn't planning to come in, he'd say, “Here's a Lawton Smith mask, you be me tomorrow.” I learned a completely new discipline-eye movements and fields and the fundus. I even learned how to use an indirect (ophthalmoscope). Nothing was routine. Lawton found something to learn and teach about every patient.

JDT: And when you returned to Philadelphia in 1966…

NJS: Alpers had been replaced by Dick Chambers as chair of neurology at Jefferson. Chambers did not believe that there was any such thing as a neuro-ophthalmologist, and he did everything to make my life difficult. I had a nice offer from the Barrow Institute in Phoenix, but my family was in Philadelphia, and my Dad was sick. I resigned from Jefferson and took refuge at Wills. Schlezinger allowed me to run his neuro-ophthalmology clinic two days a week. Tom Duane gave me constant encouragement and made sure things worked out at Wills.

JDT: Describe those early years on the Wills Neuro-Ophthalmology Service…

NJS: The service grew and grew, so I recruited other neuro-ophthalmologists. Jim Corbett and Linda Orr came first. Then, when they moved on, Peter Savino and later Bob Sergott joined me. We started to see so many patients at Wills that we could publish clinical papers with huge numbers. We were supported by clinical superstars like Bob McDonald, Lov Sarin, Jay Federman, the Spaeths, and Bill Annesley. If they couldn't find anything in the eye to explain vision loss, they sent it to us. Walsh and Cogan made trips to Philadelphia to show their support. I remember Cogan taking notes in the front row of one Wednesday noon conference. Afterwards, he congratulated me and said, “I never thought of it that way.”

I went on research expeditions to study treponemes at Tuskegee and Venezuela with Smith, and he asked me to join the faculty of his fabulously successful Bascom Palmer Neuro-Ophthalmology Course. Then Hoyt invited me to speak at Leeds Castle on pituitary tumors. Bob Daroff, Joel Glaser, Smith, Hoyt, and I formed a tight group. We started the Neuro-Ophthalmic Pathology Club in 1969, which later became the Walsh (Society). Then in 1975, Tom Carlow had the brilliant idea to organize the Rocky Mountain Neuro-Ophthalmology Club. The people we were training now had a focus to present their work.

JDT: When did you join the University of Pennsylvania faculty?

NJS: In 1976, Arthur Asbury, the chair of neurology at Penn in those years, was nice enough to give the Wills neuro-ophthalmology group our own ward-one-third of the inpatient beds at the Hospital of the University of Pennsylvania (HUP). At the same time, I became director of the neuro-ophthalmology service at the Scheie Eye Institute, the ophthalmology department of Penn. So we kept our outpatient service at Wills and added outpatient services at Scheie, inpatient services at HUP and at the Children's Hospital. No other program in neuro-ophthalmology had that kind of activity going on!

But in 1978, when I was 40, my wagon suddenly slowed down…

JDT: What happened?

NJS: I had a heart attack on the airplane coming back from the American Academy of Ophthalmology meeting in Kansas City. I was admitted to St. Mary's Hospital in Philadelphia. After I had aortic balloon placement, I arrested and was put on a lidocaine drip. Somehow I survived in spite of what I can only describe as various attempts on my life by incompetent doctors.

JDT: Do you think this experience has affected how you care for patients?

NJS: Yes, I teach patients to take responsibility for their care. I go overboard trying to explain things. No patient leaves the room without understanding the options and being encouraged to think them through. I give them everything I can possibly give them.

JDT: And what about your teaching style with doctors?

NJS: I have a lot of Bernie Alpers in me: spank them until they get it right. If they get it right, embrace them; if they don't, the heck with them. By the way, most of my students give me more than I give them. They keep me alert and give me a quality of life that is wonderful.

NJS: In 1982, I got a marvelous opportunity to take Joel Glaser's place at Bascom Palmer while he was on sabbatical leave in Israel. I liked them, and they liked me. I lived in the residents' clinic. Every Bascom Palmer resident had access to me every moment. And I had a Jackson neurology resident rotating with me. It was PGH all over again.

I began coming down to Bascom Palmer every winter for five months. They were glad to see me come and glad to see me go-in Miami and in Philadelphia! I am a high maintenance guy.

Anyway, I was going full speed ahead in spite of a stent here, a stent there. A man who has his first heart attack at the age of 36 lives in the moment. But in 1986, my heart got so much worse that I had to give up medicine. A year later, I began volunteering my time at Bascom Palmer. In 1995, Joel Glaser and I left Bascom Palmer to start a neuroscience center at Mercy Hospital. But we missed not having students and residents. When Carmen Puliafito became chair at Bascom Palmer in 2001, Joel and I rejoined the staff. Now we split our time between Bascom Palmer, the Cleveland Clinic in Fort Lauderdale, and a nearby private office.

JDT: Now, at age 69, and after several heart attacks and stents and open heart surgery, are you running all over South Florida to see patients?

NJS: Yes, attached at the hip to Joel Glaser. Without his friendship and counsel I would never had survived.

JDT: How would you sum up your place in neuro-ophthalmology?

NJS: People cannot take themselves too seriously when I'm around. I've never been much of a scientist or theoretician, but I remember what I've seen and heard, and I have seen a lot of patients. While I'm solving the medical problem, I am also trying to take care of the patient's emotional needs and educating the patient and the student doctor.

JDT: Is neuro-ophthalmology different now from when you started?

NJS: I think so. The Journal has taken off, the NANOSNET is thriving, and people are looking more at the applications of controlled studies. Roy Beck changed forever the way we think about neuro-ophthalmology. We used to run little comedy acts that amused us.

JDT: But we still worship the wonderful anecdote, the good story. Has that changed?

NJS: We still love anecdotes, but we treat them differently. For instance, in the Walsh meeting, we used to interrupt and harass the presenter and say, “Here's my logic for what this is going to be-a yellow-breasted warbler.” Now we are more respectful. The presentations are more authoritative, better researched, more scientific. We do not know the answers. And the audience is much larger. We've gained something and lost something.

JDT: Is it true to say that you have bounced back from one near-death experience after another, medically and personally?

NJS: I took a neuropsych test once that concluded that not only do I have more chaos in my life, I am able to tolerate it. I do it with laughter.

JDT: People are drawn to you…the self-deprecating humor, the risk-taking, the flashes of brilliance, the feeling that, maybe more than anyone else in our field, you are in touch with something…

NJS: I would shrivel up without the attention, even though I never quite believed I deserved it. I'll tell you a story. When I was eight years old, I brought home my elementary school report card to my father. So did my brother and sister. They had perfect grades. My father looked at my report card and saw that all the grades were erased. So he took me off to the principal's office and asked for an explanation. The principal looked up my grades and said that they were perfect. My father looked at me quizzically. Then he smiled. He didn't say anything. He realized that I had erased the grades because I thought that I was a better judge of my performance than the teachers were. I didn't think I deserved a perfect score, and I didn't want my father to be fooled. I don't get fooled by accolades. That's why I am always out there performing. But being Schatz all the time is tiring…

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